Trigeminal Neuralgia

The trigeminal nerve is one of the cranial nerves in the head. It is actually a pair of nerves that runs on each side of the head and has three branches, with each branch controlling sensation in different parts of the face.

Patients who have this form of neuralgia are normally women over age 50. It is often an inherited condition that is associated with high blood pressure and multiple sclerosis.

The pain that patients feel typically originates from an irritation of the nerve when it comes in contact with an artery or vein at the base of the brain. It can also be caused by a tumor.

Common symptoms of trigeminal neuralgia include sudden onset of pain in the face or jaw that most people associate with an injury to the head or face or dental problems. Some patients have intermittent pain that is extremely intense. Others report persistent burning pain across the face and jaw. The condition runs in cycles with patients experiencing several attacks over a short period of time. It may not return for months or years, but most when it returns, it can be more frequent and more severe.

Simple activities, such as brushing your teeth, smiling or even talking, can trigger an attack.

In some cases, medication can help, but others may need surgery to control their pain.

WakeMed’s neurosurgeons perform three procedures that help patients get relief from this painful condition.

Microvascular Decompression

Microvascular decompression surgery relieves pressure on the nerve root by carefully moving the blood vessel away from the site of compression. While this is the most effective surgery for pain relief, it is the most invasive and requires a craniotomy.

Patients who have classic trigeminal neuralgia benefit most from this surgery. These patients are those who have more frequent, intense pain that is almost like an electrical shock.

The surgery is done under general anesthesia with patients constantly monitored to ensure the nerves remain functional and uninjured. The surgeon makes a small incision behind the patient’s ear, exposing the brain covering called the dura. The dura is cut to reach the cerebellum so that the brain stem can be accessed. Using minimally invasive techniques, the surgeon dissects the nerves to reach the trigeminal nerve. A small sponge is placed between the nerve and the vessel that is causing the compression. The skull is reconstructed, and layers of tissues are stitched back in place.

Most patients are hospitalized for two days and will be weaned off pain and/or anticonvulsant medication over time. Many times, a craniotomy can cause headaches for the first few days. This can be controlled with either prescription or over-the-counter medications.

Once home, patients will not be able to drive and will have exercise limitations for about a week. Walking is the best form of exercise and should be done with supervision. Also, patients should not lift objects weighing more than five pounds and should avoid bending for a few weeks. Sutures from surgery will be removed within seven to 14 days.

Percutaneous Stereotactic Rhizotomy

This outpatient procedure uses heat to destroy part of the painful nerve. The surgeon inserts a hollow needle into the cheek near the nerve at the base of the skull. An inducer is wound through the needle to the nerve. Once at the site of the compressed nerve, the surgeon runs a current through the electrode, which destroys part, but not all, of the nerve.

Patients recover for about four to six hours and then are able to go home. Most patients will have swelling and pain on their cheek for a few days, which can be controlled with ice packs and medication. Since the procedure causes some numbness in the face, care needs to be taken when shaving, eating or drinking. Patients normally start with a soft diet for a few weeks and will be shown how to do exercises to strengthen the area. Sometimes it is helpful to use a safety razor at first.

Percutaneous Balloon Compression

This is another outpatient procedure that uses a hollow needle through the cheek to reach the trigeminal nerve. A balloon is run through the catheter and inflated at the painful site. The inflation of the balloon injures the nerve, which blocks the pain.

After the procedure, patients go home and recover. Patients have numbness in the face, so they have to be careful when eating, shaving and drinking. Sometimes the numbness is temporary, but it may be permanent in some cases.

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